Postoperative Nomogram for Predicting Cancer-Specific Mortality in Medullary Thyroid Cancer

Does the extent of neck surgery based on preoperative calcitonin level influence survival in medullary thyroid carcinoma: a retrospective tertiary centre experience

INTRODUCTION

Medullary thyroid carcinoma (MTC) is a rare thyroid cancer arising from the calcitonin-secreting parafollicular cells. Previous studies suggested a preoperative calcitonin level >200ng/l is an indication for prophylactic lateral neck dissection (LND) to remove micrometastases and improve survival outcomes.

METHODS

This retrospective single-centre study assessed the efficacy of preoperative calcitonin levels as a marker for determining need for prophylactic LND in MTC. Data were obtained on demographics, preoperative calcitonin levels, size and laterality of index tumour, type of neck dissection (central neck dissection (CND), LND), nodes removed, levels with involved nodes, number of nodes histologically involved, mortality, adjuvant therapy and locoregional recurrence.

RESULTS

A total of 33 patients were identified from St George's University Hospitals NHS Foundation Trust between 1 January 2001 and 19 August 2021; 8 were excluded for data quality issues. Of the 18 classified with a high preoperative calcitonin level (>200ng/l), 10 (56%) had a LND and 8 (44%) had a CND. In the low-calcitonin group, three (43%) patients had a CND only and four (57%) had a LND. There was no difference in absolute or disease-free survival between the low and high groups (p=0.960, p=0.817), or between those who had a CND and LND in the high-calcitonin group (p=0.607, hazard ratio (HR) 0.55; p=0.129, HR 8.78).

CONCLUSION

There was no statistically significant difference in outcomes between high and low calcitonin groups. A selective approach to performing LND in MTC patients based on clinical and imaging findings suggesting disease presence in the lateral neck should be explored further.

Fundamentals and recent advances in the evaluation and management of medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a rare primary neuroendocrine thyroid carcinoma that is distinct from other thyroid or neuroendocrine cancers. Most cases of MTC are sporadic, although MTC exhibits a high degree of heritability as part of the multiple endocrine neoplasia syndromes. REarranged during Transfection (RET) mutations are the primary oncogenic drivers and advances in molecular profiling have revealed that MTC is enriched in druggable alterations. Surgery at an early stage is the only chance for cure, but many patients present with or develop metastases. C-cell-specific calcitonin trajectory and structural doubling times are critical biomarkers to inform prognosis, extent of surgery, likelihood of residual disease, and need for additional therapy. Recent advances in the role of active surveillance, regionally directed therapies for localized disease, and systemic therapy with multi-kinase and RET-specific inhibitors for progressive/metastatic disease have significantly improved outcomes for patients with MTC.

Survival in medullary thyroid carcinoma patients who fail to achieve a biochemical cure: implications of postoperative 1-month calcitonin levels and targeted therapy

PURPOSE

The survival rate of patients with medullary thyroid carcinoma (MTC) who fail to achieve a biochemical cure after surgery is reduced. This study aimed to investigate the prognostic factors affecting the survival of MTC patients who do not achieve a biochemical cure after surgery.

METHODS

Cox univariate and multivariate proportional hazard models were used to determine the influence of different variables on overall survival (OS). Pearson's chi-square test was used for categorical variables, and paired t-test was used for continuous variables.

RESULTS

In our study of 277 MTC patients treated between 2012 and 2022, there were 96 with raised postoperative 1-month calcitonin (Ct) levels (0-9.52 pg/ml). The overall survival (OS) rates of patients with high postoperative 1-month Ct values at 1, 3, and 5 years were 97.9%, 94.6%, and 86.8%, respectively. The univariate analysis revealed that patients with a postoperative 1-month Ct > 441.9 pg/ml had a greater risk of mortality than patients with postoperative 1-month Ct values ranging from 9.52 to 73.4 pg/ml (p = 0.043). Subsequent analyses revealed that receiving targeted therapy did not improve the OS of patients with distant metastasis among those with high postoperative 1-month Ct values (p = 0.527).

CONCLUSION

This study confirmed that MTC patients who did not achieve biochemical remission after surgery had an increased risk of death when the Ct level was > 441.9 pg/ml 1 month after surgery. Additionally, for MTC patients who have not achieved biochemical remission and have experienced disease progression or distant metastasis after surgery, the use of targeted therapy does not prolong survival.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer

BACKGROUND

This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC).

METHODS

Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity.

RESULTS

Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 ​cm were more likely in men (vs. women: OR 2.47, p ​< ​0.001) and Hispanic patients (vs. White patients: OR 1.52, p ​= ​0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p ​= ​0.002; Hispanic: OR 1.44, p ​= ​0.038) and experienced longer time to surgery (Black: HR 0.66, p ​< ​0.001; Hispanic: HR 0.71, p ​< ​0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p ​= ​0.022).

CONCLUSIONS

Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

Well-defined survival outcome disparity across age cutoffs at 45 and 60 for medullary thyroid carcinoma: a long-term retrospective cohort study of 3601 patients

Background

Medullary thyroid cancer (MTC) is a challenging malignancy. The survival outcome of MTC based on AJCC staging system does not render a discriminant classifier among early stages.

Methods

3601 MTC patients from 2000 to 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Smooth curve fitting, Cox proportional hazard regression and competing risk analysis were applied.

Results

A linear correlation between age and log RR (relative risk of overall death) was detected. Overlaps were observed between K-M curves representing patients aged 45-50, 50-55, and 55-60. The study cohort was divided into 3 subgroups with 2 age cutoffs set at 45 and 60. Each further advanced age cutoff population resulted in a roughly "5%" increase in MTC-specific death risks and an approximately "3 times" increase in non-MTC-specific death risks.

Conclusions

The survival outcome disparity across age cutoffs at 45 and 60 for MTC has been well defined.

Novel prognostic nomogram for predicting recurrence-free survival in medullary thyroid carcinoma

AIMS

Recently, there have been attempts to improve prognostication and therefore better guide treatment for patients with medullary thyroid carcinoma (MTC). In 2022, the International MTC Grading System (IMTCGS) was developed and validated using a multi-institutional cohort of 327 patients. The aim of the current study was to build upon the findings of the IMTCGS to develop and validate a prognostic nomogram to predict recurrence-free survival (RFS) in MTC.

METHODS AND RESULTS

Data from 300 patients with MTC from five centres across the USA, Europe, and Australia were used to develop a prognostic nomogram that included the following variables: age, sex, AJCC stage, tumour size, mitotic count, necrosis, Ki67 index, lymphovascular invasion, microscopic extrathyroidal extension, and margin status. A process of 10-fold cross-validation was used to optimize the model's performance. To assess discrimination and calibration, the area-under-the-curve (AUC) of a receiver operating characteristic (ROC) curve, concordance-index (C-index), and dissimilarity index (D-index) were calculated. Finally, the model was externally validated using a separate cohort of 87 MTC patients. The model demonstrated very strong performance, with an AUC of 0.94, a C-index of 0.876, and a D-index of 19.06. When applied to the external validation cohort, the model had an AUC of 0.9.

CONCLUSIONS

Using well-established clinicopathological prognostic variables, we developed and externally validated a robust multivariate prediction model for RFS in patients with resected MTC. The model demonstrates excellent predictive capability and may help guide decisions on patient management. The nomogram is freely available online at https://nomograms.shinyapps.io/MTC_ML_DFS/.

Operative Management of Thyroid Disease in Older Adults

As the population ages, both domestically and globally, clinicians will increasingly find themselves navigating treatment decisions for thyroid disease in older adults. When considering surgical treatment, individualizing risk assessment is particularly important, as older patients can present with very different health profiles. While fit, independent individuals may benefit from thyroidectomy with minimal risk, those with multiple comorbidities and poor functional status are at higher risk of perioperative complications, which can have adverse health effects and detract from long-term quality of life. In order to optimize surgical outcomes for older adults, strategies for accurate risk assessment and mitigation are being explored. Surgical decision-making also should consider the characteristics of the thyroid disease being treated, given many benign thyroid disorders and some well-differentiated thyroid cancers can be appropriately managed nonoperatively without compromising longevity. Shared decision-making becomes increasingly important to respect the health priorities and optimize outcomes for older adults with thyroid disease. This review summarizes the current knowledge of thyroid surgery in older adults to help inform decision-making among patients and their physicians.

Diagnostic, Prognostic, and Predictive Role of Ki67 Proliferative Index in Neuroendocrine and Endocrine Neoplasms: Past, Present, and Future

The introduction of Ki67 immunohistochemistry in the work-up of neuroendocrine neoplasms (NENs) has opened a new approach for their diagnosis and prognostic evaluation. Since the first demonstration of the prognostic role of Ki67 proliferative index in pancreatic NENs in 1996, several studies have been performed to explore its prognostic, diagnostic, and predictive role in other neuroendocrine and endocrine neoplasms. A large amount of information is now available and published results globally indicate that Ki67 proliferative index is useful to this scope, although some differences exist in relation to tumor site and type. In gut and pancreatic NENs, the Ki67 proliferative index has a well-documented and accepted diagnostic and prognostic role and its evaluation is mandatory in their diagnostic work-up. In the lung, the Ki67 index is recommended for the diagnosis of NENs on biopsy specimens, but its diagnostic role in surgical specimens still remains to be officially accepted, although its prognostic role is now well documented. In other organs, such as the pituitary, parathyroid, thyroid (follicular cell-derived neoplasms), and adrenal medulla, the Ki67 index does not play a diagnostic role and its prognostic value still remains a controversial issue. In medullary thyroid carcinoma, the Ki67 labelling index is used to define the tumor grade together with other morphological parameters, while in the adrenal cortical carcinoma, it is useful to select patients to treated with mitotane therapy. In the present review, the most important information on the diagnostic, prognostic, and predictive role of Ki67 proliferative index is presented discussing the current knowledge. In addition, technical issues related to the evaluation of Ki67 proliferative index and the future perspectives of the application of Ki67 immunostaining in endocrine and neuroendocrine neoplasms is discussed.

A proposed grading scheme for predicting recurrence in medullary thyroid cancer based on the Ki67 index and metastatic lymph node ratio

PURPOSE

The Ki67 index and lymph node ratio (LNR) have been proposed as components of alternative pathological classification schemes, but the most appropriate classification for patients with medullary thyroid cancer (MTC) remains unknown. The aim of the present study was to examine the usefulness of a new grading system combining the Ki67 index and LNR as a predictor of prognostic and disease-free survival (DFS) in MTC.

METHODS

We conducted a retrospective study of patients with MTC who were registered at Sun Yat-sen University Cancer Center, Guangzhou, P. R. China from June 2003 to October 2021. The DFS rates were assessed using risk-adjusted Cox proportional hazard regression modeling to explore the relationship among pathological features, nutritional status and DFS. The Ki67 index (cutoff value: 5% and 10%) and LNR (cutoff value: 0.2 and 0.3) were combined to create a new grading system.

RESULTS

In total, 101 matched patients were assessed. The integrated grading system showed better separation of Kaplan Meier (KM) curves for DFS. As the grading stage progressed, there was a significant stepwise decrease in DFS, which was better than Ki67, LNR and N staging alone. According to the grading system, the high-risk group had a worse prognosis.

CONCLUSION

The proposed grading scheme demonstrated a better prognostic performance in MTC patients than the Ki67, LNR and N staging alone. However, larger scale studies are needed to further verify our findings.

Development and validation of a nomogram to predict cancer-specific survival in middle-aged patients with papillary thyroid cancer: A SEER database study

Background

Thyroid cancer (TC) accounts for more than 90% of endocrine tumours and is a typical head and neck tumour in adults. The aim of this study was to develop a predictive tool to predict cancer-specific survival (CSS) in middle-aged patients with papillary thyroid carcinoma (PTC).

Methods

The patients from 2004 to 2015 were randomly divided into a training cohort (n = 25,342) and a internal validation cohort (n = 10,725). The patients from 2016 to 2018 were treated as an external validation cohort (n = 11353). COX proportional hazard model was used to screen meaningful independent risk factors. These factors were constructed into a nomogram to predict CSS in middle-aged patients with PTC. The performance and accuracy of the nomogram were then evaluated using the concordance index (C-index), calibration curve and the area under the curve (AUC). The clinical value of nomogram was evaluated by decision curve analysis (DCA).

Results

Age, gender, marriage, tumour grade, T stage, N stage, M stage, surgery, chemotherapy, and tumour size were independent prognostic factors. The C-indexes of the training, internal validation, and external validation cohorts were 0.906, 0.887, and 0.962, respectively. The AUC and calibration curves show good accuracy. DCA shows that the clinical value of the nomogram is higher than that of Tumour, Node and Metastasis (TNM) staging.

Conclusion

We developed a new prediction tool to predict CSS in middle-aged patients with PTC. The model has good performance after internal and external validation, which can be friendly to help doctors and patients predict CSS.

A prediction model for the 5-year, 10-year and 20-year mortality of medullary thyroid carcinoma patients based on lymph node ratio and other predictors

Aim

To explore the predictive value of lymph node ratio (LNR) for the prognosis of medullary thyroid carcinoma (MTC) patients, and constructed prediction models for the 5-year, 10-year and 20-year mortality of MTC patients based on LNR and other predictors.

Methods

This cohort study extracted the data of 2,093 MTC patients aged ≥18 years undergoing total thyroidectomy and neck lymph nodes dissection. Kaplan-Meier curves and log-rank tests were performed to compare survival curves between LNR < 15% group and LNR ≥ 15% group. All data was divided into the training set (n = 1,465) and the testing set (n = 628). The random survival forest model was constructed in the training set and validated in the testing set. The area under the curve (AUC) was employed for evaluating the predictive ability of the model.

Results

The 5-year, 10-year and 20-year overall survival (OS) and cause-specific survival (CSS) of MTC patients with LNR <15% were higher than those with LNR ≥15%. The OS was 46% and the CSS was 75% after 20 years' follow-up. The AUC of the model for the 5-year, 10-year, and 20-year OS in MTC patients was 0.878 (95%CI: 0.856-0.900), 0.859 (95%CI: 0.838-0.879) and 0.843 (95%CI: 0.823-0.862) in the training set and 0.845 (95%CI: 0.807-0.883), 0.841 (95%CI: 0.807-0.875) and 0.841 (95%CI: 0.811-0.872) in the testing set. In the training set, the AUCs were 0.869 (95%CI: 0.845-0.892), 0.843 (95%CI: 0.821-0.865), 0.819 (95%CI: 0.798-0.840) for the 5-year, 10-year and 20-year CCS in MTC patients, respectively. In the testing set, the AUCs were 0.857 (95%CI: 0.822-0.892), 0.839 (95%CI: 0.805-0.873) and 0.826 (95%CI: 0.794-0.857) for the 5-year CCS, 10-year CCS and 20-year CCS in MTC patients, respectively.

Conclusion

The models displayed good predictive performance, which might help identify MTC patients might have poor outcomes and appropriate interventions should be applied in these patients.

Tumor Grade Predicts for Calcitonin Doubling Times and Disease-Specific Outcomes After Resection of Medullary Thyroid Carcinoma

Background: Tumor grade is a new validated prognostic factor for medullary thyroid cancer (MTC). Calcitonin doubling time can predict MTC recurrence. We aimed to describe the association of tumor grade with calcitonin doubling and its effect on disease-specific outcomes times after resection. Methods: A retrospective analysis of MTC patients who underwent resection at a single tertiary-care cancer center between 1986 and 2017 were evaluated. Tumors were designated as high-grade MTC if two head and neck pathologists identified mitotic index ≥5 per 2 mm2, tumor necrosis, or a Ki67 proliferative index ≥5% within the tumor. Calcitonin doubling time was calculated using a validated calculator with at least three consecutive levels. Using Cox proportional hazards models, outcomes evaluated included locoregional relapse-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS). Results: Among 117 patients, 95 were low grade and 22 high grade. Median follow-up was 70.2 months. High-grade patients demonstrated significantly faster calcitonin doubling times when compared with low-grade patients (8.51 ± 3.22 months vs. 38.42 ± 11.19 months; p < 0.001). In addition, most high-grade patients (66.7%) had calcitonin doubling times less than 1 year compared with fewer low-grade patients (1.0%; p < 0.001). High- and low-grade patients were further stratified by those who had calcitonin doubling times less than or greater than 2 years-a previously validated prognostic cutoff point. For patients with calcitonin doubling times less than 2 years, 70% were high grade, while 30% were low grade (p < 0.001). On multivariate analysis comparing grade and calcitonin doubling times, high-grade patients had significantly worse LRFS (hazards ratio [HR] 4.77 [confidence interval; CI 1.19-8.81]), DMFS (HR 7.25 [CI 2.36-22.28]), and OS (HR 6.04 [CI 1.85-19.72]; p < 0.05 for all), while calcitonin doubling times less than 2 years had worse DMFS (HR 7.22 [CI 1.05-49.75]). High-grade patients with calcitonin doubling times less than 2 years had associated worse LRFS and OS (both p < 0.05) compared with low-grade patients. Conclusions: The majority of high-grade MTC patients have calcitonin doubling times less than 2years. Close monitoring should be advocated for patients assessed to have high-grade tumors as they are at risk for poor disease-specific outcomes and structural recurrence.

Novel Therapeutics and Treatment Strategies for Medullary Thyroid Cancer

Medullary thyroid cancer is a rare thyroid malignancy with unique management considerations. In general, small intrathyroidal tumors are cured by total thyroidectomy with central compartment dissection, while large tumors and those with disease spread to regional lymph nodes and distant organs (most commonly lung, liver, and bone) are more difficult to cure. The last decade has seen significant progress in the treatment of advanced MTC, largely due to the discovery and availability of novel targeted therapies, including new drugs specifically targeting the RET protooncogone.

Construction and Validation of a Prediction Model for Identifying Clinical Risk Factors of Lateral Lymph Node Metastasis in Medullary Thyroid Carcinoma

PURPOSE

Medullary thyroid carcinoma (MTC) is a rare but highly invasive malignancy, especially in terms of cervical lymph node metastasis. However, the role of prophylactic lateral lymph node dissection (LLND) is still controversial. We hereby aim to explore the risk factors of lateral lymph node metastasis (LLNM) in patients with MTC to guide clinical practice.

PATIENTS AND METHODS

The clinicopathological characteristics of patients with MTC from the Surveillance, Epidemiology, and End Results (SEER) Program and the Second Affiliated Hospital of Chongqing Medical University were reviewed and analyzed. Univariate and multivariate logistics regression analyses were used to screen the risk factors of LLNM in patients with MTC.

RESULTS

Four variables, including male gender, multifocality, extrathyroidal invasion (EI), and large tumor size (all p < 0.05), were identified as potential independent factors of LLNM in patients with MTC. Based on these results, an individualized prediction model was subsequently developed with a satisfied C-index of 0.798, supported by both internal and external validation with a C-index of 0.816 and 0.896, respectively. We also performed the decision curve analysis (DCA) and calibration curve, which indicated a remarkable agreement in our model for predicting the risk of LLNM.

CONCLUSION

We determined that various clinical characteristics, male gender, multifocality, EI, and large tumor size, were significantly associated with LLNM in patients with MTC. Thus, a validated prediction model utilizing readily available variables was successfully established to help clinicians make individualized clinical decisions on MTC management, especially regarding whether the LLND is necessary for patients with clinical negative lateral lymph node involvement and the frequency of follow-up without LLND.

International Medullary Thyroid Carcinoma Grading System: A Validated Grading System for Medullary Thyroid Carcinoma

PURPOSE

Medullary thyroid carcinoma (MTC) is an aggressive neuroendocrine tumor (NET) arising from the calcitonin-producing C cells. Unlike other NETs, there is no widely accepted pathologic grading scheme. In 2020, two groups separately developed slightly different schemes (the Memorial Sloan Kettering Cancer Center and Sydney grade) on the basis of proliferative activity (mitotic index and/or Ki67 proliferative index) and tumor necrosis. Building on this work, we sought to unify and validate an internationally accepted grading scheme for MTC.

PATIENTS AND METHODS

Tumor tissue from 327 patients with MTC from five centers across the United States, Europe, and Australia were reviewed for mitotic activity, Ki67 proliferative index, and necrosis using uniform criteria and blinded to other clinicopathologic features. After reviewing different cutoffs, a two-tiered consensus grading system was developed. High-grade MTCs were defined as tumors with at least one of the following features: mitotic index ≥ 5 per 2 mm², Ki67 proliferative index ≥ 5%, or tumor necrosis.

RESULTS

Eighty-one (24.8%) MTCs were high-grade using this scheme. In multivariate analysis, these patients demonstrated decreased overall (hazard ratio [HR] = 11.490; 95% CI, 3.118 to 32.333; P < .001), disease-specific (HR = 8.491; 95% CI, 1.461 to 49.327; P = .017), distant metastasis-free (HR = 2.489; 95% CI, 1.178 to 5.261; P = .017), and locoregional recurrence-free (HR = 2.114; 95% CI, 1.065 to 4.193; P = .032) survivals. This prognostic power was maintained in subgroup analyses of cohorts from each of the five centers.

CONCLUSION

This simple two-tiered international grading system is a powerful predictor of adverse outcomes in MTC. As it is based solely on morphologic assessment in conjunction with Ki67 immunohistochemistry, it brings the grading of MTCs in line with other NETs and can be readily applied in routine practice. We therefore recommend grading of MTCs on the basis of mitotic count, Ki67 proliferative index, and tumor necrosis.

Lobectomy may be more appropriate for patients with early-stage medullary thyroid cancer older than 60 years old

PURPOSE

Clinical guidelines presently recommend total thyroidectomy for the treatment of medullary thyroid cancer (MTC). This study was aimed to investigate whether lobectomy could be the initial treatment for stage I MTC patients.

METHODS

The retrospective study was based on data from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. The risk factors of survival were estimated by the univariate and multivariate Cox proportional-hazards model. The effect of age on death risk was estimated using restricted cubic splines. Survival curves were constructed according to the Kaplan-Meier method.

RESULTS

A total of 988 stage I MTC patients was included in the study. Among them, 506 (51.2%) MTC patients received lobectomy and 482 (48.8%) received total thyroidectomy. The only independent prognostic factor for overall survival (OS) and disease-specific survival (DSS) was age, according to univariate and multivariate Cox regression analysis. The hazard ratio (HR) increased relatively slowly with age growing under the age of approximately 60 years. However, the death risk of MTC patients began to rise sharply with increasing age above 60 years. For patients under the age of 60, a significant survival difference for OS and DSS was observed between the lobectomy group and total thyroidectomy group (p < 0.05). However, for patients aged above 60, no significant survival difference was observed for OS or DSS (p > 0.05).

CONCLUSION

Total thyroidectomy was an appropriate treatment for stage I MTC patients under the age of 60, which was consistent with the recommendation of the clinical guidelines. However, for those over the age of 60, lobectomy may be explored as a better surgical option. The findings may provide the evidence base for improving the clinical management of stage I MTC patients. Further prospective multicenter clinical studies are needed including information regarding RET status as well as calcitonin and CEA levels.

Development and validation of pretreatment nomogram for disease-specific mortality in gastric cancer-A competing risk analysis

Background

In several reports, gastric cancer nomograms for predicting overall or disease‐specific survival have been described. The American Joint Committee on Cancer (AJCC) introduced the attractiveness of disease‐specific mortality (DSM) as an endpoint of risk model. This study aimed to develop the first pretreatment gastric cancer nomogram for predicting DSM that considers competing risks (CRs).

Methods

The prediction model was developed using data for 5231 gastric cancer patients. Fifteen prognosticators, which were registered at diagnosis, were evaluated. The nomogram for DSM was created as visualizations of the multivariable Fine and Gray regression model. An independent cohort for external validation consisted of 389 gastric cancer patients from a different institution. The performance of the model was assessed by discrimination (Harrell's concordance (C)‐index), calibration, and decision curve analysis. DSM and CRs were evaluated, paying special attention to host‐related factors such as age and Eastern Cooperative Oncology Group performance status (ECOG PS), by using Gray's univariable method.

Results

Fourteen prognostic factors were selected to develop the nomogram. The new nomogram for DSM exhibited good discrimination. Its C‐index of 0.887 surpassed that of the American Joint Committee on Cancer (AJCC) clinical staging (0.794). The C‐index was 0.713 (AJCC, 0.582) for the external validation cohort. The nomogram showed good performance internally and externally, in the calibration and decision curve analysis. Host‐related factors including age and ECOG PS, were strongly correlated with competing risks.

Conclusions

The newly developed nomogram accurately predicts DSM, which can be used for patient counseling in clinical practice.

Effects of Social Determinants of Health Care on Pediatric Thyroid Cancer Outcomes in the United States

OBJECTIVE

To identify social determinants of health care that are associated with poorer pediatric well-differentiated thyroid cancer (WDTC) outcomes and increased stage at presentation.

STUDY DESIGN

Using the SEER database (Surveillance, Epidemiology, and End Results), we retrospectively gathered data on pediatric WDTC across the United States between 1973 and 2015.

SETTING

All patients between 0 and 19 years old with a diagnosis of WDTC were included.

METHODS

Patient variables were analyzed for relationships to AJCC stage at presentation (American Joint Committee on Cancer), overall survival, and disease-specific survival.

RESULTS

Among 3913 patients with pediatric thyroid cancer, 3185 were female (81.4%), 3366 had papillary thyroid cancer (85.3%), and 367 had follicular thyroid cancer (9.4%). Two- and 5-year overall and disease-specific survival approached 100%. However, when outcomes were analyzed by specific populations, male sex, non-Caucasian race, poverty, and language isolation were linked to worse overall survival. Male sex and poverty were associated with poorer disease-specific survival. Regarding overall AJCC stage at presentation, male sex and Black race were related to higher overall presenting AJCC stage. Later AJCC T stage at presentation was seen in male, Hispanic, Asian, and Black patients. There were no variables significantly related to following through with recommended surgery.

CONCLUSION

Pediatric WDTC continues to carry an excellent prognosis in the United States. However, when we consider specific populations, the social determinants of health care affect survival and disease burden at presentation: male sex, poverty, language isolation, and race affected survival and/or AJCC stage at presentation in pediatric WDTC.

Predicting Outcomes in Sporadic and Hereditary Medullary Thyroid Carcinoma over Two Decades

Background: Medullary thyroid cancer (MTC) can be associated with significant morbidity and mortality in advanced cases. Hence, we aimed to identify factors at the time of MTC surgery that predict overall survival (OS), disease-specific survival (DSS), locoregional recurrence/persistence (LR), and distant metastases (DM). Methods: We performed a retrospective study of clinicopathologic, radiological, and laboratory data in MTC patients who underwent thyroidectomy at Mayo Clinic from January 1995 to December 2015. Results: We identified 163 patients (mean age 48.4 years, 48% males), 102 with sporadic MTC and 61 with hereditary disease (n = 46 multiple endocrine neoplasia [MEN] 2A, n = 3 MEN 2B, n = 12 familial MTC) with a median follow-up time of 5.5 years. On univariate analysis, age >55 years, male sex, DM at the time of surgery (M1), lateral neck lymph node (LN) involvement (N1b), gross extrathyroidal extension (ETE), American Joint Committee on Cancer (AJCC) stage 3/4, tumor size (T) 3/4, tumor size, and postoperative calcitonin (Ctn) and carcinoembryonic antigen (CEA) were significant predictors of worse OS and DSS. On multivariable analysis, both gross ETE (hazard ratio [HR] 4.62, 6.58) and M1 (HR 5.11, 10.45) remained significant predictors of worse OS as well as DSS, while age >55 years (HR 3.21), male sex (HR 2.42), and postoperative Ctn (HR 1.002 for every 100 pg/mL increase) were significant only for worse OS. On univariate analysis, male sex, M1, N1b, gross ETE, stage 3/4, T 3/4, tumor size, number of LNs involved, and postoperative Ctn were significant predictors of LR and DM; age >55 years was additionally significant for DM. On multivariable analysis, gross ETE (HR 3.16, 5.93) and N1b (HR 4.31, 4.64) remained significant predictors of LR and DM; ratio of resected/involved LN (HR 10.91) was additionally predictive for LR and postoperative Ctn (HR 1.003 for every 100 pg/mL increase) for DM. Conclusions: Disease burden at initial surgery, especially gross ETE, lateral neck LN involvement, and DM, as well as the biochemical response to surgery appear to be more important than demographic factors in terms of MTC prognosis. These findings highlight the importance of rigorous perioperative assessment to better predict MTC outcomes.

Prophylactic Lateral Neck Dissection for Medullary Thyroid Carcinoma is not Associated with Improved Survival

BACKGROUND

Patients with medullary thyroid carcinoma (MTC) often receive lateral lymph node dissection with total thyroidectomy when calcitonin levels are elevated, even in the absence of structural disease, but the effect of this intervention on disease-specific outcomes is not known.

PATIENTS AND METHODS

We retrospectively reviewed patients from 1986 to 2017 who underwent thyroidectomy with curative intent for MTC at our institution. The association of disease-specific survival and clinicopathologic features was examined using univariate and multivariate Cox regression.

RESULTS

We identified 316 patients who underwent curative resection for MTC. Overall and disease-specific survival were 76% and 86%, respectively, at 10 years. To investigate the effect of prophylactic ipsilateral lateral lymph node dissection, we analyzed 89 patients without known structural disease in the neck lymph nodes at the time of resection and preoperative calcitonin > 200 pg/ml, of whom 45 had an ipsilateral lateral lymph node dissection (LND) and 44 did not. There were no differences in tumor size or preoperative calcitonin levels. There was no difference at 10 years in cumulative incidence of recurrence in the neck (20.9% LND vs. 30.4% no LND, p = 0.46), cumulative incidence of distant recurrence (18.3% vs. 18.4%, p = 0.97), disease-specific survival (86% vs. 93%, p = 0.53), or overall survival (82% vs. 90%, p = 0.6).

CONCLUSION

Lateral neck dissection in the absence of clinical or radiologic abnormal lymph nodes is not associated with improved survival in patients with MTC.

Postoperative Nomogram for Predicting Cancer-Specific and Overall Survival among Patients with Medullary Thyroid Cancer

BACKGROUND

Medullary thyroid carcinoma (MTC) accounts for 1%-2% of thyroid cancer in the United States based on the latest Surveillance, Epidemiology, and End Results (SEER) data, and this study aimed to construct a comprehensive predictive nomogram based on various clinical variables in MTC patients who underwent total thyroidectomy and neck lymph nodes dissection.

METHODS

Data regarding 1,237 MTC patients who underwent total thyroidectomy and neck lymph nodes dissection from 2004 to 2015 were obtained from the SEER database. Univariate and multivariate Cox regression analyses were used to screen for meaningful independent predictors. These independent factors were used to construct a nomogram model, a survival prognostication tool for 3- and 5-year overall survival, and cancer-specific survival among these MTC patients.

RESULT

A total of 1,237 patients enrolled from the SEER database were randomly divided into the training group (n = 867) and the test group (n = 370). Univariate and multivariate Cox regression analyses were used to identify meaningful independent prognostic factors (P < 0.05). Tumor size, age, metastasis status, and LNR were selected as independent predictors of overall survival (OS) and cancer-specific survival (CSS). Finally, two nomograms were developed, and the predicted C-index of overall survival (OS) and cancer-specific survival (CSS) rate in the training group was 0.828 and 0.904, respectively. The predicted C-index of overall survival (OS) and cancer-specific survival (CSS) rate in the test group was 0.813 and 0.828.

CONCLUSION

Nomograms constructed by using various clinical variables can make more comprehensive and accurate predictions for MTC patients who underwent total thyroidectomy and neck lymph nodes. These predictive nomograms help identify postoperative high-risk MTC patients and facilitate patient counseling on clinical prognosis and follow-up.

CD133 Expression in Medullary Thyroid Cancer Cells Identifies Patients with Poor Prognosis

CONTEXT

The identification of markers able to determine medullary thyroid cancer (MTC) patients at high-risk of disease progression is critical to improve their clinical management and outcome. Previous studies have suggested that expression of the stem cell marker CD133 is associated with MTC aggressiveness.

OBJECTIVE

To evaluate CD133 impact on disease progression in MTC and explore the regulatory mechanisms leading to the upregulation of this protein in aggressive tumors.

PATIENTS

We compiled a series of 74 MTCs with associated clinical data and characterized them for mutations in RET and RAS proto-oncogenes, presumed to be related with disease clinical behavior.

RESULTS

We found that CD133 immunohistochemical expression was associated with adverse clinicopathological features and predicted a reduction in time to disease progression even when only RET-mutated cases were considered in the analysis (log-rank test P < 0.003). Univariate analysis for progression-free survival revealed CD133 expression and presence of tumor emboli in peritumoral blood vessels as the most significant prognostic covariates among others such as age, gender, and prognostic stage. Multivariate analysis identified both variables as independent factors of poor prognosis (hazard ratio = 16.6 and 2; P = 0.001 and 0.010, respectively). Finally, we defined hsa-miR-30a-5p, a miRNA downregulated in aggressive MTCs, as a CD133 expression regulator. Ectopic expression of hsa-miR-30a-5p in MZ-CRC-1 (RETM918T) cells significantly reduced CD133 mRNA expression.

CONCLUSIONS

Our results suggest that CD133 expression may be a useful tool to identify MTC patients with poor prognosis, who may benefit from a more extensive primary surgical management and follow-up.

Medullary Thyroid Cancer in Patients Older than 45-Epidemiologic Trends and Predictors of Survival

Simple Summary

Sporadic medullary thyroid cancer can occur anytime in life although they tend to present at a later age (≥45 years old) when the tumors are more easily discernible or become symptomatic. We present, in this study, a group of patients diagnosed with medullary thyroid cancer at or after 45 years of age when they are more likely to develop sporadic forms of medullary thyroid cancer with regard to their natural history and prognosis. In this study, we evaluated factors affecting survival in such patients. We found that the incidence of medullary thyroid cancer in patients ≥45 years of age is increasing. Our findings suggest that patients should be offered surgical resection at an early stage to improve their outcomes.

Abstract

Sporadic medullary thyroid cancer (MTC) can occur anytime in life although they tend to present at a later age (≥45 years old) when the tumors are more easily discernible or become symptomatic. We aimed to identify the factors affecting the survival in patients ≥45 years of age diagnosed with MTC. We analyzed the Surveillance, Epidemiology, and End Results (SEER) registry from 1973–2016 focusing on patients ≥45 years of age with MTC as an isolated primary. A total of 2533 patients aged ≥45 years with MTC were identified. There has been a statistically significant increase of 1.19% per year in the incidence of MTC for this group of patients. The disease was more common in females and the Caucasian population. Most patients had localized disease on presentation (47.6%). Increasing age and advanced stage of presentation were associated with worse survival with HR 1.05 (p < 0.001) and HR 3.68 (p < 0.001), respectively. Female sex and surgical resection were associated with improved survival with HR 0.74 (p < 0.001) and 0.36 (p < 0.001), respectively. In conclusion, the incidence of MTC in patients ≥45 years of age is increasing. Patients should be offered surgical resection at an early stage to improve their outcomes.

Association between age and disease specific mortality in medullary thyroid cancer

BACKGROUND

The aim of this study was to evaluate the association between age and disease specific mortality (DSM) among adults diagnosed with medullary thyroid cancer (MTC).

METHOD

Surveillance, Epidemiology, and End Results (SEER-18) was used to analyze adult MTC patients stratified by age (18-64, 65-79, ≥80 years). Associations between patient demographics, tumor size, nodal status, metastatic disease, and extent of surgery on DSM was assessed with multivariable Cox regression.

RESULTS

Among 1457 patients with MTC, 1008 (69.2%) were younger adults, 371 (25.5%) older adults, and 78 (5.4%) were super-elderly. A significantly higher proportion of older adults and super-elderly had less than the recommended operation for MTC. On multivariable analysis, older adults and super-elderly were 2.9 and 6.7 times more likely to have an increased DSM (HR:2.91, 95% CI: 1.83-4.63; p < 0.001 and HR: 6.70, 95%CI: 3.69-12.20; p < 0.001). Extent of surgery or lymphadenectomy did not affect DSM.

CONCLUSIONS

Increased age is an independent predictor of DSM in patients with MTC.

Grading of medullary thyroid carcinoma on the basis of tumor necrosis and high mitotic rate is an independent predictor of poor outcome

Medullary thyroid carcinoma (MTC) is a rare nonfollicular cell-derived tumor. A robust grading system may help better stratify patients at risk for recurrence and death from disease. In total, 144 MTC between 1988 and 2018 were subjected to a detailed histopathologic evaluation. Clinical and pathologic data were correlated with disease specific survival (DSS), local recurrence free survival (LRFS)  and distant metastasis free survival (DMFS). Median age was 53 years (range: 3-88). Median tumor size was 1.8 cm (range: 0.2-11). Lymph node metastases were present in 84 (58%) cases while distant metastases at presentation were found in 9 (6%) patients. Seven (5%) had ≥5 mitoses/10 HPFs. Tumor necrosis was present in 30 cases (20%) while lymphovascular invasion occurred in 41 (28%) of tumors. Extra-thyroidal extension was found in 44 (31%) and positive margins were seen in 19 (14%). There was a strong correlation between increasing tumor size and tumor necrosis (p < 0.001). Median follow up was 39 months. In univariate analysis, male gender, higher American Joint Committee on Cancer (AJCC) stage group, larger tumor size, tumor necrosis, high mitotic index (≥5/10 HPF), nodal status, size of largest nodal metastasis, and elevated postoperative serum calcitonin predicted worse DSS, LRFS, and DMFS (p < 0.05). Extra-thyroidal extension correlated with DSS and DMFS while positive margins and distant metastasis at presentation imparted worse DSS (p < 0.05). In multivariate analysis, tumor necrosis and mitotic activity (5 mitosis/10 HPFs as the cutoff) were the only independent predictors for DSS (p = 0.008 and 0.026, respectively). Tumor necrosis was the sole independent prognostic factor for LRFS and DMFS (p = 0.001 and 0.003, respectively). The presence of tumor necrosis and high mitotic rate are powerful independent prognostic factors in MTC and outperform serum calcitonin and stage. We propose a grading system based on tumor necrosis and mitotic activity to better stratify MTC patients for counseling, post-resection surveillance, and therapy.

A Nomogram for Predicting Cancer-Specific Survival of Patients with Gastrointestinal Stromal Tumors

Background

The aim of this study was to construct a nomogram to predict the prognosis of patients with gastrointestinal stromal tumor (GIST).

Material/Methods

We enrolled 4086 GIST patients listed in the SEER database from 1998 to 2015. They were separated to 2 groups: an experimental group (n=2862) and a verification group (n=1224). A nomogram was constructed by using statistically significant prognostic factors.

Result

A nomogram that included age, sex, marital status, tumor location, grade, SEER stage, tumor size, and surgical management was developed. It can be used to predict overall survival (OS), while adding AJCC 7^th TNM stage can predict cancer-specific survival (CSS). The C-index used to forecast OS and CSS nomograms was 0.778 (95% CI, 0.76–0.79) and 0.818 (95% CI, 0.80–0.84), respectively.

Conclusions

The nomogram can effectively predict 3- and 5-year CSS in patients with GIST, and its use can improve clinical practice.

A Model for the Prediction of Survival in Patients With Upper Tract Urothelial Carcinoma After Surgery

Objective:

We aimed to formulate and validate prognostic nomograms that can be used to predict the prognosis of patients with upper tract urothelial carcinoma (UTUC).

Methods:

By consulting the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were surgically treated for UTUC between 2004 and 2013. Variables were analyzed in both univariate and multivariate analyses. Nomograms were constructed based on independent prognostic factors. The prognostic nomogram models were established and validated internally and externally to determine their ability to predict the survival of patients with UTUC.

Results:

A total of 4990 patients were collected and enrolled in our analyses. Of these, 3327 patients were assigned to the training set and 1663 to the validation set. Nomograms were effectively applied to predict the 3- and 5-year survivals of patients with UTUC after surgery. The nomograms exhibited better accuracy for predicting overall survival (OS) and cancer-specific survival (CSS) than the tumor-node-metastasis (TNM) staging system and the SEER stage in both the training and validation sets. Calibration curves indicated that the nomograms exhibited high correlation to actual observed results for both OS and CSS.

Conclusions:

The nomogram models showed stronger predictive ability than the TNM staging system and the SEER stage. Precise estimates of the prognosis of UTUC might help doctors to make better treatment decisions.

Long-Term Oncologic Outcomes After Curative Resection of Familial Medullary Thyroid Carcinoma

INTRODUCTION

Long-term outcomes after curative resection in patients with germline RET mutations and medullary thyroid cancer (MTC) are highly variable and mutation-specific oncologic outcomes are not well-described.

METHODS

Sixty-six patients identified from 1986 to 2017 from a single-institution cancer database were assessed for recurrence and survival using Kaplan-Meier estimates, and correlated with clinicopathologic features using log-rank or Cox proportional hazards.

RESULTS

Median follow-up was 9.3 years (range 0.3-31.5), median tumor diameter was 1.5 cm (range 0.1-7.5), and preoperative calcitonin was known in 41 patients [median 636 (range 0-9600)]. Overall survival (OS) of the cohort was 94% at 10 years, the cumulative incidence of locoregional recurrence was 38% at 10 years, and 19/24 (79%) patients underwent repeat neck operation. The cumulative incidence of distant recurrence was 27% at 10 years. Predictors of distant recurrence were tumor size, positive lymph nodes, and pre- and postoperative carcinoembryonic antigen, but not calcitonin. M918T mutation-bearing patients had 10-year distant recurrence-free survival of 0%, compared with 83% in all other patients (p < 0.001), and equivalent 10-year OS (100% vs. 92%; p = 0.49).

CONCLUSIONS

Structural and metastatic recurrence is common in patients with germline RET mutations, and MTC and can occur 20 years after initial treatment, however survival remains high. Management should focus on optimal surveillance strategies and long-term control of structural disease.

Clinico-pathologic and dynamic prognostic factors in sporadic and familial medullary thyroid carcinoma: an Israeli multi-center study

OBJECTIVE

Multiple clinical, pathological and biochemical variables, including the response to initial treatment, are associated with medullary thyroid carcinoma (MTC) prognosis. Studies that include separate analyses of familial and sporadic MTC patients followed for long period are scarce. This study evaluated the association between baseline clinico-pathologic variables and response to initial treatment and short- and long-term disease outcomes in sporadic and familial MTC.

METHODS

Patients treated for MTC at four tertiary medical centers were retrospectively analyzed. Clinical and pathological data were collected. The outcomes measured included disease persistence 1 year after diagnosis, disease persistence at last follow-up, disease-related mortality (DRM) and all-cause mortality.

RESULTS

The study enrolled 193 patients (mean age: 48.9 ± 18.7, 44.7% males), of whom 18.1% were familial cases. The mean follow-up period was 10.1 ± 9.4 years (8.5 ± 8.1 in sporadic and 16.9 ± 11.6 in familial MTC). Disease persistence 1-year after diagnosis and at last follow-up was detected in 56.1 and 60.4% patients, respectively. All-cause and DRM were 28.5 and 12.6%, respectively. Extra-thyroidal extension (ETE) and distant metastases (DM) were associated with disease persistence at last follow-up. ETE and DM were also significantly associated with DRM. Complete remission 1 year after diagnosis had high correlation with no evidence of disease at last follow-up (Cramer's V measure of association 0.884, P < 0.001) and with 100% disease-specific survival (Cramer's V measure of association 0.38, P < 0.001).

CONCLUSIONS

Apart from clinico-pathologic parameters, close correlation was found between 1-year status and long-term prognosis. These results underscore the importance of combining classical and dynamic factors for both sporadic and familial MTC prognostication and treatment decision making.

Development and validation of prognostic nomograms for medullary thyroid cancer

Background

This aim of study was to develop and validate clinical nomograms to predict the survival of patients with medullary thyroid cancer.

Patients and methods

Patient data were collected from the Surveillance, Epidemiology, and End Results database between 2004 and 2013. All included patients were randomly assigned into the training and validation sets. Multivariate analysis using Cox proportional hazards regression was performed, and nomograms were constructed. Model performance was evaluated by discrimination and calibration plots.

Results

A total of 1,657 patients were retrospectively analyzed. The multivariate Cox model identified age, tumor size, extrathyroidal extension, N stage, and M stage as independent covariates associated with overall survival (OS) and cancer-specific survival (CSS). Nomograms predicting OS and CSS were constructed based on these covariates. The nomograms predicting both OS and CSS exhibited superior discrimination power to that of TNM staging system in the training and validation sets. Calibration plots indicated that both the nomograms in OS and CSS exhibited high correlation to actual observed results.

Conclusion

The nomograms established in this study provided an alternative tool for prognostic prediction, which may thereby improve individualized assessment of survival risks and lead to the creation of additional clinical therapies.

Serum calcitonin nadirs to undetectable levels within 1 month of curative surgery in medullary thyroid cancer

OBJECTIVE

Because serum calcitonin (CT) is a reliable marker of the presence, volume, and extent of disease in medullary thyroid cancer (MTC), both the ATA and NCCN guidelines use the 2-3 month post-operative CT value as the primary response to therapy variable that determines the type and intensity of follow up evaluations. We hypothesized that the calcitonin would nadir to undetectable levels within 1 month of a curative surgical procedure.

SUBJECTS AND METHODS

This retrospective review identified 105 patients with hereditary and sporadic MTC who had at least two serial basal CT measurements done in the first three months after primary surgery.

RESULTS

When evaluated one year after initial surgery, 42 patients (42/105, 40%) achieved an undetectable basal calcitonin level without additional therapies and 56 patients (56/84, 67%) demonstrated a CEA within the normal reference range. In patients destined to have an undetectable CT as the best response to initial therapy, the calcitonin was undetectable by 1 month after surgery in 97% (41/42 patients). Similarly, in patients destined to have a normalize their CEA, the CEA was within the reference range by 1 month post-operatively in 63% and by 6 months in 98%. By 6 months after curative initial surgery, 100% of patients had achieved a nadir undetectable calcitonin, 98% had reached the CEA nadir, and 97% had achieved normalization of both the calcitonin and CEA.

CONCLUSION

The 1 month CT value is a reliable marker of response to therapy that allows earlier risk stratification than the currently recommended 2-3 month CT measurement.

Tumor-induced mortality in adult primary supratentorial glioblastoma multiforme with different age subgroups

AIM

To assess the independent determinants of tumor-induced mortality in different age subgroups after considering competing risk (CR).

METHODS

Data were extracted from the SEER database. The independent determinants of tumor-induced mortality were defined by CR analysis and validated by conditional inference trees. A CR nomogram was created based on the proportional subdistribution hazard model.

RESULTS

The different age subgroups had their own independent determinants of tumor-induced mortality. Using these variables, a CR nomogram was built with good discrimination and calibration.

CONCLUSION

When conducting population-based cohort studies, a CR analysis is recommended for cancers with short survival and high mortality. A CR nomogram represents the first attempt at a predictive model for quantifying tumor-induced mortality.

Nomogram Predicting Cause-Specific Mortality in Nonmetastatic Male Breast Cancer: A Competing Risk Analysis

Introduction: Male breast cancer (MBC) is a rare tumor with few cases for research. Using the Surveillance, Epidemiology, and End Results program database, we carried out a competing risk analysis in patients with primary nonmetastatic MBC and built a predictive nomogram. Materials and Methods: We extracted primary nonmetastatic MBC patients according to the inclusion and exclusion criteria. Cumulative incidence function (CIF) and proportional subdistribution hazard model were adopted to explore risk factors for breast cancer-specific death (BCSD) and other cause-specific death (OCSD). Then we built a nomogram to predict the 3-year, 5-year and 8-year probabilities of BCSD and OCSD. C-indexes, Brier scores and calibration curves were chosen for validation. Results: We identified 1,978 nonmetastatic MBC patients finally. CIF analysis showed that the 3-year, 5-year and 8-year mortalities were 5.2%, 10.6% and 16.5% for BCSD, and 6.1%, 9.6% and 14.4% for OCSD. After adjustment of Fine and Gray models, black race, PR (-), advanced T/N/grade and no surgery were independently associated with BCSD. Meanwhile, elderly, unmarried status, advanced AJCC stage and no chemotherapy resulted in OCSD more possibly. A graphic nomogram was developed according to the coefficients from the Fine and Gray models. The calibration curves displayed exceptionally, with C-indexes nearly larger than 0.700 and Brier scores nearly smaller than 0.100. Conclusion: The competing risk nomogram showed good accuracy for predictive prognosis in nonmetastatic MBC patients. It was a useful implement to evaluate crude mortalities of BCSD and OCSD, and help clinicians to choose appropriate therapeutic plans.

Clinical Validation of the Prognostic Stage Groups of the Eighth-Edition TNM Staging for Medullary Thyroid Carcinoma

CONTEXT

Despite advances in thyroid cancer staging systems, considerable controversy about the current staging system for medullary thyroid carcinoma (MTC) continues.

OBJECTIVE

We aimed to evaluate the prognostic performance of the current eighth edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control TNM staging system (TNM-8) and the alternative proposed prognostic stage groups based on recursive partitioning analysis (TNM-RPA).

DESIGN, SETTING, AND PATIENTS

We retrospectively analyzed 182 patients with MTC treated at a single tertiary Korean hospital between 1995 and 2015.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Survival analysis was conducted according to TNM-8 and TNM-RPA. The area under the receiver-operating characteristic curve (AUC), the proportion of variation explained (PVE), and the Harrell concordance index (C-index) were used to evaluate predictive performance.

RESULTS

Under TNM-8, only two (1.1%) patients were downstaged compared with the seventh edition of the AJCC TNM staging system (TNM-7). The AUC at 10 years, PVE, and C-index were 0.679, 8.7%, and 0.744 for TNM-7 and 0.681, 8.9%, and 0.747 for TNM-8, respectively. Under TNM-RPA, 104 (57.14%) patients were downstaged compared with TNM-8. TNM-RPA had better prognostic performance with respect to cancer-specific survival (AUC at 10 years, 0.750; PVE, 20.9%; C-index, 0.881).

CONCLUSIONS

The predictive performance of the revised TNM-8 in patients with MTC has not changed despite its modification from TNM-7. The proposed changes in TNM-RPA were statistically valid and may present a more reproducible system that better estimates cancer-specific survival of individual patients.

BI-RADS 3-5 microcalcifications can preoperatively predict breast cancer HER2 and Luminal a molecular subtype

Purpose

To investigate associations between breast cancer molecular subtype and the patterns of mammographically detected calcifications.

Results

Identified were 93 (19.1%) Luminal A, 242 (49.9%) Luminal B, 108 (22.2%) HER2 and 42 (8.7%) basal subtypes. In univariate analysis, the clinicopathological parameters and BI-RADS 3–5 microcalcifications, which consisted 9 selected features was significantly associated with breast cancer molecular subtype (all P < 0.05). Among subtypes, multivariate analysis showed that calcification >2 cm in range (OR: 1.878, 95% CI: 1.150 to 3.067) and calcification > 0.5 mm in diameter (OR:2.206, 95% CI: 1.235 to 3.323) was independently predictive of HER2 subtype. The model showed good discrimination for predicting HER2 subtype, with a C-index of 0.704. In addition, multivariate analysis showed that calcification morphology (amorphour or coarse heterogenous calcifications OR: 2.847, 95% CI: 1.526 to 5.312) was independently predictive of Luminal A subtype. The model showed good discrimination for predicting Luminal A subtype, with a C-index of 0.74. And we demonstrated that amorphour or coarse heterogenous calcifications were associated with a higher incidence of Luminal A subtype than pleomorphic or fine linear or branching calcifications. There was no significant difference between breast cancer subtypes (Luminal B vs. other; Basal vs. other) and the patterns of mammographically detected calcifications.

Materials and Methods

Mammographic images of 485 female patients were included. The correlation between mammographic imaging features and breast cancer subtype was analyzed using Chi-square test, univariate and binary logistic regression analysis.

Conclusions

This study shows that BI-RADS 3–5 microcalcifications can be conveniently used to facilitate the preoperative prediction of HER2 and Luminal A molecular subtype in patients with infiltrating ductal carcinoma.